A two month old infant is brought in by EMS in full cardiac arrest. The initial rhythm they found was asystole (flat line). According to EMS, the baby was a premature infant, born at 25 weeks, and was recently discharged with a monitor. Paramedics arrived to find the baby on the bed, without a pulse, and no bystander CPR. Mom (16 y/o) was hysterical and could not provide any additional information, except the baby was fine two hours ago when she put her to sleep after feeding.
Primary survey reveals an uncuffed endotracheal tube orally placed, with equal breath sounds. Initial rhythm in the ED is also asystole. There is no IV access. As CPR is continued, an IO is quickly obtained (no obvious other IV access).
1. Should you give high dose epinephrine?
Routine use of high dose epinephrine is not recommended, as it did not change outcome (although it did increase ROSC (return of spontaneous circulation)).(1,2)
2. Should you give atropine?
Although atropine is recommended for adults in asystole, it is not recommended for young children and infants. (3). Although the reasons for this are unclear to me and I could not find any information on the Internet regarding this. If anyone knows why atropine is not used in children in asystole, let me know.
3. Is 2 thumb-encircling hands versus 2 finger chest compressions better in infants?
There were two manikin and two animal studies that showed the 2 thumb-encircling hands technique of chest compressions with circumferential thoracic squeeze produced higher coronary perfusion pressures. So, for infants, this may be preferred. However, when only one rescuer is there, the transition is easier with the 2-finger technique so this is preferred with single rescuers. The goal is for compression of the lower part of the sternum to a depth of approximately 1/3 the anterior-posterior diameter of the chest. (1)
4. When can you consider using a cuffed ET tube?
You can use a cuffed ET tube in infants and children now. (Although they are not recommended for newborns.) Studies have not shown any greater risk of complications, and in some situations, the cuffed tube may be advantageous. (1,2). If using a cuffed ET tube, making sure the cuff pressure is correct is important. Additionally, in out of hospital pediatric arrests with short transport times, it is recommended that EMS NOT intubate, but just provide Bag Valve Mask (1,2).
5. Are lay people doing CPR in the field supposed to check for a pulse?
No, according to the ILCOR the pulse check has been eliminated as an assessment for the lay rescuer. It simply takes to long (usually longer than 10 seconds) which leads to interruptions in chest compressions. (1,2). Laypersons should simply start CPR for any unresponsive infant or child who is not breathing. For health care professionals, they can check for a pulse, but if they are not sure in 10 seconds, they should start CPR. (1,2).
In spite of ACLS, we were unable to resuscitate this infant, as was expected. By the time the baby loses their heart beat, they have likely been apnic for some time. (Infants with un-witnessed cardiac arrest frequently suffer a respiratory arrest, followed by a cardiac arrest.)
Coding babies and children are much more emotional for me. These cases are always coroner’s cases, so parental contact with the baby may be considered by some controversial. However, I do let the family hold the baby (the nurse is in the room with the family). This is supported also by the Association of SIDS and Infant Mortality. (4)
In this case, when the mom was ready, we wrapped the baby in a blanket and let the mother hold her baby one last time.
1. The International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations for Pediatric and Neonatal Patients: Pediatric Basic and Advanced Life Support. ILCOR. Pediatrics 2006 May; 117(5):e955-77. Entire manuscript accessed at: “http://pediatrics.aappublications.org/cgi/content/full/117/5/e955”
2. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112: IV-1 – IV-5. Entire manuscript available at: “http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-1”
3. Caggiano RM. Asystole: Treatment and Medication. E-medicine. Aug 7, 2008. Accessed at: “http://emedicine.medscape.com/article/757257-treatment”
4. Association of SIDS and Infant Mortality Programs. The Unexpected Death of an Infant or Child: Standards for Services to Families. 2004. Accessed at: “http://www.asip1.org/images/ASIP_Standards.pdf“